HIT Standards Transcript


HIT Standards Committee Meeting 5/15/2009


Great, thank you. Good morning and welcome to the first meeting of the health health Standards Committee.At the conclusion of this meeting the public will be invited to make comments. Those of you in the room will be invited to a microphone. Those of you on the phone you can make your comments via the phone. People on the web if you want to type in the comments we will make sure they’re part of the record. At the conclusion the materials will be made public on the website, a transcript and a summary of the meeting in about a week’s time. A reminder to those here and on the phone if you would please identify yourself so the transcriber can note your comment.

With that I will have each member introduce themselves and then we will go to the phone. Janet?

I’m Janet Corrigan.

John Derr, I’m golden living. Glad to be here.

Anne Castro.

Christopher Chute.

Dixie Baker.

Good morning, John Perlin.

David Blumenthal, I will add my welcome to you in just a moment.

I’m John Halamka.

I’m Jodi Daniel.

Jim Walker.

Gina Perez.

Judy Murphy.

I’m David McCallie, Jr..

I’m John Klimek.

Kevin Hutchinson.

Good morning, Liz Johnson.

Hi, Stanley M. Huff.

I’m Douglas Fridsma.

Hi, good morning, I’m Steven Findlay.

Good morning, Linda Dillman.

I’m Jamie Ferguson.

Members on the telephone —

Good morning, this is J. Marc Overhage. Good morning, everyone.

Anyone else on the phone? Okay. I’ll turn it over to Dr. Blumenthal.

Thank you, Judy. I once had the opportunity to do advance work for a senator. We always picked a room that was too small so that we could be sure that it looked like it was a popular place to be. I appreciate all of you being here, members of the Standards Committee and members of the public. Appreciat yourwillingnesss. And the enormous opportunities and challenges that are associated with the legislation and the goals that it has set out for the United States of America in the area of Health Information Technology. This committee is a committee that will really help us get the technology, or at least the standards, right for this activity. I do want to draw you back to the larger picture — the larger picture which plains why we’re here. You can’t pick up the newspapers now without seeing discussions about the future of our healthcare system. One issue is the issue of providing Americans access to high quality healthcare. The other is the discussion about how to organize our healthcare system so it can deliver on that promise of coverage. In the organization of that healthcare system there is no part of the picture, no part of the change that is more important than how we manage information. No part of the management of the information is more important than the technologies that we use to provide that management capability. That management capability is going to make healthcare better and more efficient. If it fails to do that we will have great disappointment and great jeopardy for our healthcare system going forward. We all in inviting you here are hoping you can help us deliver. Because ever statutory deadlines, especially the requirement that we meet the promise of the legislation that American physicians and hospitals and other providers of care that wish to be “Meaningful Users” of Health Information Technology by 2011, that we make it possible for those well- intended to take advantage of the incentives that the Congress has made available to them. That planning back from the 2011 deadlines creates very, very strict imperatives that have morphed us to bring you here with less time than we might have liked, less ability to sort of very carefully plan your agenda than we might have liked. But hope you will stick with us while we move forward with parallel processing in multiple venues. We are working on multiple programs and multiple policy directives at the same time. We convened our Health Information Technology policy committee earlier in the week. We convened you today because there was a deadline that we do. We also wanted to get you here to learn who is on the committee and begin to work together. I’m grateful to the two Johns that surround me here, John Perlin and John Halamka for taking responsibility positions in group. They are going to more than earn the very modest nonmonetary compensation that we’re able to provide them. [ Laughter ] We are trying to keep ourselves in this discussion constant focused on health and efficiency and both health for individuals and populations.

“Meaningful Use,” which is in some ways the driving concept and very useful concept, is something that we think of always in terms of health and the health of individuals and the health of populations. I urge you in your thinking when talk being standards and technologies to have in mind how will our decisions lead to “Meaningful Use” and how will “Meaningful Use” lead to the improvement of a chronic illness or the management of a long-term care problem, or whatever the agenda is. Try to keep in mind the application to people in hospitals, doctors’ offices, long-term care facilities. With that grounding, I think, we have a much higher probability of producing results that are usable and leave space for innovation in the healthcare system as we go forward. So, again, let me thank you for being here. I’m happy to now surrender the podium to the two Johns.

Thank you very much, David, for your inspiring start to this set of work. I think all of us are enthusiastic about the aspirations that you laid out. It’s not about the technology, it’s about the technology as a vehicle to improving the health and the care that can be provided. The words resonate with all. I think there’s a demand to be able to meet the aspirations. More over we feel of the urgency, not just because of the national need, let me thank you all for your commitment. The urgency is prescribed by the national need, but it’s locked down this statute. It really compels us to a good bit of work in a rapid amount of time. In many ways this will be the most complex meeting. It’s one where we set the agenda. The pieces are just beginning to come into play. As we chatted before, John Halamka, our hope is to emulate Wayne greets ski and skate to where the puck will be. I hope it provides enough clarity despite the ambiguity, but leaves open the work that needs to occur afterwards.If I might take the prerogative to take a few seconds. I came into the Department of Veterans affairs in the late ’90s. When colon cancer was diagnosed it was often late stage. Over a period of time as Electronic Health Record supported a transfer formation the care did become safer, more accessible, and more affordable. I know that journey that led to the ability to serve those that serve our country more effectively it inspires me to want to help contribute to the broader journey. It’s far more complex. It’s not a single integrated health system, it’s much messier, there’s lots of moving parts. This committee brings together many of the moving parts.We so much appreciate the lead, Dr. Blumenthal.

Wonderful to work with you all. I think we have an amazing opportunity right now. We have the alignment policy. We have regulation. We have insentives. In the past couple of years we’ve done good things with working on technology. We’ve created standards, we’ve done certification. But implementation is not aligned. There’s not been resources to do it, the imperatives and urgency. Now I see an alignment that has never occurred before. I think our measure of success should be “Meaningful Use,” real use of these technologies, real exchange of data by 2011 and beyond. In this country there’s been a lot of barriers to he can changing da — exchanging data. There’s been gaps and limitations, but there’s not been a will to break down silos and actually exchange data and we’ll do it to improve the care of the population. Starting today, as we as a committee gather and begin to work on skating to where the puck of “Meaningful Use” will be — it should be our goal to now take this great foundation that David has laid for us and figure out the standards that will get us to true implementation to data exchange by 2011. We just shouldn’t just say that the status quo is doing just fine. We’re already doing prescriptions and labs. We should say let’s stretch ourselves. I believe when we declare the standards we should not set the bar so high that will leave all rural of America behind and the small small doctor’s office without the ability to reach the bar, but nor should we accept the status quo. To me with these 25 great minds that represent so many different parts of healthcare, let’s work together. We’ll bet reports on where we are with regard to the standards today. And then think about how to stretch ourselves a bit to get to the “Meaningful Use” that you are looking for.

Now, I wish today we had a crisp description of what “Meaningful Use” is. [ Laughter ] But we have from the policy committee, we’ll heard from Jodi about it, a direction of where they’re heading. We met this morning and chatted with David. We will postulate to you a few ideas, planning about what “Meaningful Use” might be. David, of course, is not ready to declare today in meeting that our guess is correct. But I think as we begin this discussion and gather your input you will probably find it rationale to start thinking about medications and labs and quality, care coordination — seems like a starting point. I’m sure, we’ll hear from Jodi and Jonathan further, that we will meet a lot together in the future months. Working virtually wherever we can. I do love getting together in small rooms like this, it builds togetherness. I think we will also hear from Jodi there’s an urgency of getting it work done because we want public comment. We want to meet the requirements. I hope you didn’t have any vacation plans this summer, we’ll be on the phone together. We’ll be making a great difference. Just to end with — it’s an incredible time. Let’s grab that brass ring and let’s make a difference and change healthcare in America.

Thank you. You know, if we could give you a definition of “Meaningful Use” we would, we’re working on it. There’s also regulatory process related to “Meaningful Use,” which means that even our recommendations, your suggestions will have to go through a complicated process of public discussion. It is going to be important that all of us think about options and do what we can in a period of uncertainty to prepare for is likely to come down the pike.

[ Speaker/Audio Faint or Unclear ]

Go ahead.

Do you want to go, Jodi?

Let me introduce Jodi Daniel and ask her to take us through the process that is described. Then we will come back for further discussion about the process of our activity and initial thoughts about how we translate that urgency that is statutory and frankly the opportunity of the moment, and translate that into our activity.

Thank you, John. I have the pleasure of trying to explain some of the wisdom that we read from the statute from Congress. To help folks think about the scope of this committee is, how it relates to other activities we’re required to undertake, how it relates to the policy committee and all of that. For the members of the committee, there’s a PowerPoint. When I talked to the policy committee and talked through the language it seemed in that conversation that it might be helpful to put it in writing. I provided that to you. Just to start, the statute sets forth the committee’s purpose to recommend to the national coordinator, standards, certification criteria for use of Health Information Technology. That is the frame of what this committee is charged with. This will relate to the incentive payments. The recommendations that come out of this committee will have significant impact on the work that we’re doing with respect to the certification process, the incentive payments and the like. I do want to stress this is a federal advisory committee, the recommendations that come out of this committee are recommendations to the department. We still have to go through our process to make determination as to whether or not we will accept them. I expect we will rely heavily upon them.

With respect to the scope of the work, the statute also sets forth that any recommendations from this committee should be consistent with the federal Health Information Technology plan. The policy committee met on Monday. The policy committee sets the priorities of policy, the standards committee can best look to the standards, implementation, certification to meet the priorities that the policy committee provides to us. We see these committees working hand in hand. The Office of the National Coordinator is supporting both of them. We expect we will be the. glue between the two to understand what each group is doing so we have collaborative efforts.

The statute also requires that we update our strategic plan, that’s something we need to do internally. There’s an plan now that we can look to in the meantime but that’s a process that will be ongoing. The statute also — in — Congress set forth eight areas that the committee should begin with in making recommendations. On the next page this is where I thought it would be helpful to have it written out. It goes through the eight categories that the committee is supposed to start with, according to the statute. Just to briefly walk through. The first is on privacy and security.The second is nationwide infrastructure, standards in area. Utilization of an EHR for each person in United States.

Technologies that allow for accounting for disclosures. This is tied to the HIPAA privacy rule requirements.The committee is supposed to look at standards in that regard. Improve quality of healthcare.This is related to the requirement that Congress put out regarding breech notification requirements. We put out guidance that we’re in the process of seeking comment on. This is something we’ve already taken a step on. We’re looking for this committee to provide us guidance in that area once a year. The use of electronic systems to ensure collection of patient demographic data. The last one is technologies that address the needs of children and other vulnerable populations. Those are the Congressional starting points. Clearly there will be other areas. I think there’s a lot of room for discussion. I wanted to make sure that folks are aware of those. The responsibilities of this committee, I mentioned to make recommendations to the national coordinator. Also to recognize, harmonize or update standards. And then to provide for testing for such standards. This group can be making recommendations for NIST to do testing of standards before a formal recommendation comes to us as to a standard that we would want to include in our set of standards that the secretary recognizes.

Some of the process and how this ties into our other work. The first thing is — I think it was David that talked about our responsibility. The Health Information Technology Standards Committee has to develop a policy. There’s this statutory tie between the policy and the Standards Committee. Today we will be talking about a general schedule for how this committee plans to operate. We will plan to publish that after this meeting, presuming we’re able to accomplish that. We are require today update that schedule annually. We will be regularly adding to the schedule and then making sure we have a publication annually to give people a sense of our timeline and our issues. And to conduct open and public meetings.

I want to talk about the standards adoption process. It ties into timing and how you can helpful to provide meaningful input. The statute sets forth two processes. An expedited one for the initial set of standards, and the regular process. HHS is required to publish an interim find rule by December 31, 2009. For folks that are aware of regulatory process, that’s really fast. We will be meeting that deadline, that is our expectation. That’s why John and John suggested that the early phase of this discussion might have to be expedited so there can be an opportunity for input into that process. We will have to regularly update the standards, implementation, standards and certification criteria. This is an ongoing process that HHS will be engaged in, we will look for your input. The other point on this expedited process is Congress articulated we can rely on prior processes for identifying and recognizing standards, et cetera. To the extent that most folks know we had the prior process with the we can look to the standards and criteria that have already gone through the processes in putting fort the initial set of standards. We will take advantage of that language, as well. The normal process is that the Health Information Technology Standards Committee will make recommendations to the national coordinator. We will assume once we’ve gotten through the standards and we’re looking at new standards we would rely on this committee to provide us input. There’s a statutory process that is triggered that provides an opportunity for comment on the recommendations and for the national coordinator to consider the recommendations, to make recommendations to the secretary and for the secretary to make a decision. There’s a very detailed process to make sure we get public comment and take the time to assess the recommendations that come out of this committee.

If you turn to the last page there’s a very small flow chart. I wanted to put this into a graphic. The policy committee will provide recommendations to the national coordinator. We would bring those to the Standards Committee to let you know what came out of the policy committee and bring that link together. The Standards Committee will be making recommendations about standards, certification, implementation specifications and organizations that we should look to for standards, development, harm Mondayization, and whether or not we need to ask for some organizations to look at new areas, where there might be gaps. As I mentioned, this committee can also recommend testing of particular standards. NIST would be the entity that can do the testing. This committee may want to consider making suggestions for NIST to do testing before making final recommendations. Once they go to the Office of the National Coordinator the review and recommendations to the secretary kicks in. That’s the processes, the role of the committee, how we see this working.

Thanks. It’s pretty clear this will be a highly [ Indiscernible ] group to meet these aspirations. The golden ring really is the improvement. I know everyone comes to this table highly motivated. I’m sure that generates a lot of questions. There’s the charge within the statute. There’s the process aspect. There’s the eight domains that were idead and the things that we can anticipate. I would like to initiate conversation about how to approach our work. Let’s divide it into two pieces.

First, let’s be practical and turn to Jodi for any answers on clarification, anything you want to understand better from the statute. Janet Corrigan has a wonderful convention that has been started here. This way we will make sure to see cards that are up, if we adopt that.

Thanks. That was a great overview. The one question I had, I understand from your comments how the relationships would work when it pertains to the standards. It’s less clear to me the certification criteria process. I realize the definition of “Meaningful Use” is not settled on yet. It seems to me likely that certification criteria will not exist for the definition that is likely to emerge. Where does CCHIT fit in? What is the process for getting criteria develop that don’t exist? And what is the process of testing them? And who would do that?

I think that’s a question I should take. Actually, I will turn it back to Jodi. [ Laughter ] The answer is that we are working hard on reviewing the certification process. We are looking at alternatives. We’re going to try to bring our recommendations and thoughts to this committee and others as soon as we can do that. We’re also doing the same with “Meaningful Use.” When I referred to parallel processing that is one of the things I had in mind, this committee may have to work thinking about contingencies for a certain amount of time until the work of the Office of the National Coordinator and of the administration becomes better defined. A week ago, Monday I guess, when the HIT policy committee met I was just beginning my third week, I’m just concluding my third week here. I know if that means I’m a veteran. I would like to hide behind that recent arrival still.

Maybe this is a question for Jodi. The statute and the process that we reviewed — that’s part of what is implied —

Sure. Yeah. This committee can hear from whomever you all feel would be helpful. We could have CCHIT come and testify. The policy committee is looking at the certification process. We can also have somebody from the policy committee, or David, come and update this group on some of the thinking. To the extent that it might inform your thinking. Yes, all of that is possible.

I should have mentioned that the policy committee has formed three working groups. One of which is dealing with certification and adoption. Another of which is dealing with “Meaningful Use.” The third is discussing exchange. Privacy and security it was decided that should be — rather than having their own subgroup should be a pervasive consideration across all. We will get input from the policy committee on those topics. We have internal groups working on both topics. We’re trying very hard to get to our own thinking resolved, so we can bring that to you for your reaction. Thank you.


John and his team of volunteers have done amazing work. I’m wondering how you can exchain to us today how that will fit into what we do. Different understandings around the table about HITSBY’s work.

Sure. The healthcare information standards panel is a group of 600 volunteer organizations. These are from payers and employers, government, attorneys. They’ve come together to harmonize standards. We look at all of the possibilities.It has produced a series of deliverables. This was would we were asked to do by the previous administration. Here is a use case, provide a document to describe the standards. We now recognize that the stimulus bill, ARRA, and “Meaningful Use” requires a bit of a different construct. We’ve gone through the previously recognized and accepted standards and we’re reformatting them, rather to be use case-based to be much more data element and functionally based. For example, if it might be that e-prescribing is important for “Meaningful Use,” rather than barriering the various vocabularies, transmission standards and the way we do a prescription it is is in an index — I need to name a medicine, there’s one way to do that, that is Rx Norm. An implementer to go to this resource and much more easily pull out the standards they need. Now, again, I will turn to David and Jodi here, my understanding is when we look at this chart that all of that work, the accepted and recognized work, now reformatted to be more aligned with “Meaningful Use” is coming from a harmonization organization, therefore as an input to this committee. Should this committee identify there are gaps or extensions that entity could also receive a marching order to fix this, it would be report back to this committee.

I think everyone, myself included, is appreciative of the work that has HITSP has shown over the years. We are adopting a view that’s goal oriented, without in any way depreciating the value of technology or the expertise around this table. We want to focus it on the uses and what doctors and hospitals have to get done in their daily work. John’s concept of taking of what has done, recon figuring it so it’s related to use is a very, very useful and functional way of thinking about this. So, we don’t have time to remake the world. We have to get a lot of work done. HITSP will continue to be a very important resource for our work.

[ Speaker/Audio Faint or Unclear ]

I’m the guy that’s always the guilty party, usually stating the obvious. I will state a few obvious points. One, I’m thrilled that this committee has expanded beyond just the standards and focusing on the implementation of the standards, as well as the certification. I think in past processes focusing just on those standards and not the other two elements left the gaps in what to do with that. I think that will be very helpful. One of the things — this is the obvious things — one of the things I would encourage us to do is look at the great examples where of these standards have been implemented in the private sector. When I look at prior to do [ Indiscernible ] I was a founding CEO of sure scripts. We created a standard before it became part of the Medicare modernization act, which was very helpful. But then creating the implementation criteria. There are many examples, Delaware, Indianapolis, other places where HIEs have gone through these processes. I know that’s part of our core mission, to outreach to those areas. Even where there’s identification issues it’s one thing. I think where we will get a lot of experience is the attempt to try to implement and certify technologies.

We’re anticipating the different bodies of work. As you say it’s not just the specifications but the implementation, when one begins to consider “Meaningful Use” it’s really is that practical level of what it means to different individuals and entities. I think the statute was very foresightful and effective. That’s part of our charge to bring that. And the representation around this table is also very broad, the ability to get public input as well. That’s a process that will ground us in standards that are effectively articulated, tested, and adoptable, but also in [ Interference ] of actual practice.



Hi. This is Wes Rishel. I’ve been difficulty being heard. My virtual card is up. I wanted to let you know. [ Laughter ]

Wes, this is David Blumenthal. Let me make a short comment. I didn’t say in my opening comments, but Kevin’s comments reminded me of it. That is on innovation. One of the great fears that we hear and see in email a lot has to do with whether the federal government through the process that is being created will have the effect of — by developing complicated standards and implementation recommendations, whether we will suppress innovation in the marketplace with respect to software and end up freezing in place technologies. This is something that my office has on its radar screen constantly. We ask ourselves are we doing anything that will result in a slowing of the innovation in a field that is innovative and where the best is yet to come? With respect to Kevin’s points, it’s great to have those on the screen, but it’s also a very delicate responsibility. Where we need to ask ourselves are we asking too much? Have we left enough space? While still protecting the public. I will stop there.

Thank you. It’s very helpful.

Let’s go to Wes Rishel on the phone.

Thank you. I just — I have written about the process that has gone on before. Why like the opportunity to share that note with the committee members. My concern is the waterfall approach of producing a decide and then rolling it out to the industry without a fast feedback process or dealing with issues that come up can’t work. And hasn’t happened because there is a specific change-off of responsibility from producing the specification and having it being recognized and have it being implemented. I hope we’ll have a chance to — within the bounds of the legislation, to attempt to create a better feedback loop. On the separate comment of innovation versus standardization, I think that it’s important that we recognize that is always a balancing act. That we might have better cell phones now if they weren’t locked into certain standards for how they communicate, but likely we would have a hard time talking to our neighbor on the cell phone. The important thing is to establish processes where standards are focused on what is needed, either assure the bean counters they’re getting their value, or assure interchange or correct functionality and we establish a process for evolution of standards without throwing out investments that have been already made.

Wes, this is John Halamka. When I read the legislation and speaking with David, I believe there will be a very different set of processes that ensure accountability that is end to end. In the past there was a use case, use case writers say here’s a great use case, we’re done. Standards would be placed around it. HITSP would say we’ve met the letter, we’ve done. We would hand it off to the implementation committee, there will be certification criteria. These went from organization to organization, to organization. Rather than improve care, did we make a difference end to end? Can we be held accountable? That’s based on the stimulus and on David’s approach would we will see. This committee will be charged with much more than just the narrow standards production, but making sure there’s certified, implemented, tested and David will take responsibility for getting “Meaningful Use” out of them.

Thanks, John. That’s what I’m concerned about. I would only add to that as the standards committee we need to assure that as we move between those phases we have a way to go back and identify very specific issues that come up and fix them much faster than the full regulatory loop.

Appreciate your counsel on that. Really I’m taken by John’s framing of the alignment. It’s not just creating a product for the market, but there’s a market, the pull that the incentives have offered. It fosters innovation and the ability to implement.

There are two cards up. Dixie?

The klutz of the group, I couldn’t get my mine to stand up. There seems to be an obvious dependency here. We’re to review the recommendations of the policy committee and we don’t have a date for when the policy committee recommendations are due. Is there — do you know that date?

No. [ Laughter ] There wasn’t a date set on when recommendations, or the schedule for when recommendations will come out of the policy committee. Um, David had talked to the committee, he hopes to have them work quickly to bring back recommendations. You know, we’re — we’re sort of operating — we’re trying to get everything moving at once. It’s a bit of a challenge. In some areas for you to all move forward I think you can make some assumptions. As we have recommendations coming out of the policy committee you can work from those. You are not necessarily prohibited from talking about something. If there’s something else from a checkive wisdom of this group you think needs to be something that you take on you can raise other issues other than what comes out of the policy committee. You can also talk on other issues. If you are talking about how to come up with a schedule — I think you can say from such time as you receive a recommendation this is how you will move forward. As we get more clarity we can always revise this. This will be somewhat of a work in progress.

I would think there’s two threads of work. The policy committee delivers a policy request to us, then we would develop a schedule. But you have deadlines of 12, 31, 2009. We have to back ourselves up from that. If we wait for the policy committee we will never meet the deadline. We need contingency work, that’s our best case. “Meaningful Use,” what might that be? Exchange, what kind of things should we provide to foster exchange? Let’s have that at the ready for when the policy folks report to us.

We will take Anne’s question. And then we will break.With that let’s take a question and then talk about setting up tasks for ourselves.

Thank you. My question is related to the reality of everything else going on during this same time period, including the 5010 changes that are going to flow down into everybody we will flow down into, and the [ Indiscernible ] 10 which many people have not even started thinking about. Even though they’re in the 12 and 13 timeframes the work will be done, I know there’s incentives for providers to start using what we come out with. But they will be jumping into an immediate change. And the vendor situation will be — I will supply a product that meets the certification criteria, but I have to turn around and make major changes to it to meet the letter of the transactions that are being impacted by the 5010 and the ICD10 coding. I want to put on the table I think it would be a good idea to create a road map of all of the activities going on up through the major goal of 2014. Having that PHR out there for everybody. That’s all the same — I said PHR, but it was the 2014 goal. It’s a bigger picture, really. It’s a bigger impact. What we will do has to have a practical application to get this stuff transitioned. I know I’m already doing the planning. I already have a schedule 8 out. I know when things have to happen. I’m an insurer. I’m a key cog in the wheel of setting up when people are in a position to even take on the task, even if you give them $40,000 to do it. There’s still bigger issues out there we have to make sure we take into account. That road map idea is something that helps us. I think it will help us in our planning here, as well.

You talk about quality and efficiency. One aspect of efficiency is administrative simplification. We want to assure every payer and provider are doing the business of medicine as well as they can. How do we move to the next generation of administrative standards? Now we have a requirement to get to ICD10 by 2013. We will go from 16,000 codes to 170,000 codes. We have to now transMilt that new set of information. The standard is not capable of supporting, we have to move to 5010.

All of my providers will be retooling. They’re not going to want additional effort to have a continuum of effort from healthcare, seeing the patient, to being able to bill for it, being able to maintain a health record that helps them with their next illness. All of this is a continuum of the same information.

The joy of being a CIO, here’s a new mandate, all five are happening at the same time. This notion of how do we stage this? How do we phase this? What is reasonable?

You don’t want a failure because you didn’t take into account a provider might be more concerned about how much they’re paid than the clinical quality of care. That could happen because one standard is based on how I’m paid, another standard is based on how I take care of a patient.

Very true.

You make a great point. This is the kind of thing we hope will come out of this committee. To make sure we take those into account in how we stage standards adoption. That’s helpful.

This is Rick Stevens. I apologize for calling in late. I want to put my card up.

I was just going to say the other thing that your input can help us with is feeding this information back to our colleagues on Capitol Hill who create the mandates. But often are not aware of the full complexity that people in the real world are dealing with.

The other piece I heard — the need for having a calendar that shows what is coming down the pike.

If we anticipate it we can build into the process help, or sensitivities to get us a success.

Thank you.

Rick, we recognize your virtual card.

Thanks very much. I apologize for calling in late and not being there in person. What I’m struggling with, I think many of us do, is that it’s not clear we have a common understanding of what our measures of success are. It’s not clear that we all understand the process that will get us to a system that meets the measures of success. As an employer when I look at this Health Information Technology system I think about it in terms of fundmental values. That is transparency of healthcare costs from a doctor, nurse, patient, and payer perspective. I didn’t hear the remarks earlier, I apologize, but is there is a definition of the process that we will go through that will lead to us achieving what the expectations for this committee are? And how do I get a hold of that process?

Rick, let me just acknowledge your comments. I think they really capture a consensus of aspiration. It’s not the technology, the aspiration that Dr. Blumenthal laid out is improving health and care of individuals and populations. All those things imply a derivative set of measures. The process Jodi Daniel walked through with some degree, to be sure you are absolutely in the majority, we’re working through a process to determine how we approach. This is a complex enough aspect, there are a number of inputs we receive, the statute, the working process here, some initial insight from the policy committee, and we’ve been using the nailgy of getting to where the puck will be. Our next conversation really would to be lay out contingencies should it be asked of us to define and be able to answer, yes, this can be supported with reasonable standards. This is going to be a bit of a work in process. The best picture is the single slide in the PowerPoint that shows that relationship, as Jodi Daniel explained, there’s statutory deadlines that compel us to early action. Even in anticipation of requests, recognizing that the formal flow is from the policy committee through the national coordinator.

When I’m in DC I will see if I can line up time with Jodi to understand where Jodi is taking us, and provide my input.

Sure thing. [ Laughter ]

Your point at the outset, this is the unifying premise. So, um, with that — I think that is a good transition to help anticipate that proverbial puck. I offer up the opportunity for individuals to put contenders on, or anything that you might like to offer.

I await your guidance. [ Laughter ]

Certainly in the legislation there’s a statement about electronic prescribing and quality.

As well in there, electronic interchange of information to support continuity of healthcare. Okay — Elizabeth Johnson.

It’s obvious when the policy folks met on Monday they established three groups. It would be obvious we might want to align ourselves similarly to that and anticipate the standards that will be required by each group. Just a thought. I think we will have to go what we clearly understand and what we don’t clearly understand and start moving forward, or we will not be able to meet the deadlines that are imposed. Just a thought for consideration.

Dixie Baker.

Many of you know I have a particular interest in privacy and security. They did not form a group around that. That is an area where I have to tell you I do not know exactly what will come out of the policy committee in that area. It’s a difficult area to anticipate. It has huge implications regarding technology standards.

In reading the meeting, I think the idea that became clear to me is everyone felt it is critical that throughout all of our discussions that must be paramount. Whether or not we choose a different route, charge every working group to say this is part of the mission, you must keep this in mind.

I think the statute gives us clarity in terms of the eight domains. One is accounting for disclosure. The other is security for breech notification.This issue of authorization.

[ Overlapping Speakers ]

You are right, privacy and security and sensitive information, segmentation of specific information, as well.


One of the realities of our scope is that it’s potentially very broad. Given the statutory guidance there is a pretty large body of work, your point is well taken, that is one bolus.

In terms of anticipating “Meaningful Use,” I have heard a couple of contenders out there in the discussion thus far. E-prescribing is one. John, you may want to T it up.

From chatting with many, many people. You hear e-prescribing, you hear laboratory, you hear clinical summary exchange, and quality measurement. Those four elements seem to be very commonly discussed. Want to hear the input of others if you are hearing in your world that “Meaningful Use” might be something beyond an initial [ Indiscernible ] of those four.

What were the four?

E-prescribing, laboratory, clinical summary, and quality.

There’s a card —

There is a card.

Thank you, this is David McCallie, Jr.. Just to put something on the list to consider, someone asked me a few weeks ago what is the most important and most commonly used standard in healthcare data exchange. It was a trick question. The answer of course is facts, right. I wonder if secure messaging in response to specific HIPAA, TPNO transactions, if that should be on our list of things to do. What do we replace the facts that allows us to treat the data electronically.

What you mean is rather using AOL, Yahoo and G mail how to use promote technologies.

Right, right.

To communicate messages from stakeholder to stakeholder.

Right. It would immediately get us into the scope of authorization and authentication. How do we know who we’re talking to? Until we have confidence there are robust ways to know that we can trust that the person on the other end is who they say, we’re at risk of not getting far very fast. We will have systems we’re afraid to plug in, if you would. Secure messaging would be something that would flush out some of those issues early on. Web-based tools would be the likely leading contender. It would engage the patient, it would allow for exchange of summary documents to the consumer as a stepping stone as towards for aggregation-based sharing. It’s just a suggestion.

Sure. That was one of the use cases that HITSP worked on in 2008, that’s a body of work around that.

[ Speaker/Audio Faint or Unclear ]

You know the proposed list seemed appropriate. As I think about it from a — what we typically need clinically to take care of patients there’s a couple of things to add. It’s not only e-prescribing. We also like to know about medication ordering. And the other thing that seems to be — seems essential is some capability in a system to know what are the health issues — issues/problems to make a correlation. The third area that I would mention would be — actually I think it’s pretty doable, the text reports that physicians use. So, prime things are radiology reports and then pathology reports reports and then other things like discharge summaries, operative notes, all of which are covered by if you can pass one text document you can pass them all. I think it has great benefit. From the clinical perspective, you know, lab data, yeah. Medication data, orders and prescriptions, text documents and then that health/problem/diagnosis so you know the underlying condition of the patient are fundamental focuses we could kind of attack.

When I proposed the term clinical summary I did not define that. I’m an emergency physician, I think of it a medication list, an allergy list, and some reporting documents. There could be text that comes out of a departmental system. I think one of the interesting aspects is defining what a clinical summary might contain. It may be many of the things that you described.

Thanks, John, I was hoping you would articulate that more broadly. I think that is at a very practical what is needed.


Continuing on the theme of where the puck is going — six years ago when we were first starting to figure out e-prescribing. It was all fax, you wrote it in a tool and it faxed it to the pharmacy, there was no medication history, no refill information. At that time it was about going to where the puck was going, getting it to be a fully automated process. Now as we look at e-prescribing and think about where the puck is going it really needs — the thinking needs to expand beyond the old definition, which is new and renewal, it’s focused on medication management. If you look at medication management it now entails adherence, compliance, abuse, applicable use of medications. If we look to where the puck needs to go, we need to go beyond just the exchange of information between entities and really have standards for are we managing medication use for patient care? And do we have the standards for the management of that medication use beyond the exchange of prescription information?

I think that’s well said. Thank you. Christopher Chute. We will start there.

Thank you. I agree with much of the added perspective that’s been raised. I would add another layer. We have to careful we don’t get into the [ Indiscernible ] equivalent of fax. We can exchange information but not have its meaning effectively conveyed. I want to raise the semantics world. It’s important to have that is exchanged understandable not only by humans, but by systems that can manage and interoperate with that information. There’s the “I” word again. We have to be careful. It would be probably a great victory to have electronic interchange of humanly readable data nationally, no arguement. We have to be careful not to stop at that process. Or architect it at a way to going past that would be difficult.

Very well said. Many reports have said if all we could do is take the human readable text and go from provider to provider so humans could understand what is done that would be a great victory. Wouldn’t it also be wonderful to have decision support that you could say this problem, this med, this lab — intervene now. It has to be a journey, as Chris said. It’s not a green field out there, we know that. Doctors are not thinking in snow med CT when they write problem lists yet, but they’re starting to. We will, I hope, in this work together, say yes, better than nothing. Here is the journey to getting that vocabulary.

This is Wes, my card is up again.

Okay, a few on the table.


Anne Castro.

One of the things that has happened with standards is that they do a wonderful job of saying what you have to have on them, but it doesn’t tell you how you have to say it. When you get the printout, my example is what is the eligibility of a patient? It looks 75 different ways depending what insurer you are working with. It’s a joke because the information is conveyed 75 different ways. Vendors do not isn’t size it into — synthesize it into a single way. When you go into a physician office and you are asked to fill out the form that’s because they want the information in their face and right away, what is your problem today? What meds are on you? I’m backing up the fact that we need some some sort of a practical fast pass to medical data. We do not create something that is so complex and deep and wide that every time that you have a patient come in your office with 15 minutes that you can’t get to the medical record. You see what I’m saying?

We started with 270, 271. Then we got a vow cab.

Yeah. That’s the place we don’t usually go. That’s what I’m lobbying for. You have the list of four. We talked about text information. Go ahead and address images. You want to see the cat scan. You want to see the lab results and the x-ray. There’s no reason why that cannot not be a part of an EHR that is shared. We need to go that extra step.

Terrific. Hearing a lot of very practical guidance. I think there’s consensus.

I will encourage us to not only be practical, but to make sure we take time to step outside the very traditional medical system box. We’re trying to take the medical system through a paradigm shift to a system that is patient centered. That does call for thinking about standards and information capture in four areas. I think we want to pay special attention to how information on health behaviors is captured within the system. Second, whether or not there should be standards that have to do with treatment, patient and family caregiver management of their own condition, understanding their treatment plan. The third area, to be more patient centered, to think about how to capture and use information on patient outcomes beyond mortality. This is an enormous sector. Moving beyond mortality. Last but not least, we need to think about patient engagement and decision making. It’s an opportunity to remove waste from the system. If we engage patients in making decisions about making treatment options. I know that takes us a little out of the practical realm. We do want to be practical. But within a broader concept of where we want to be down the road. We may have opportunities in this area.

Thank you. Those points are so important.You have also recognized the patient as the center of this process. And down stream the ability to make sure that information is transportable.

I wanted to take a minute to look back at the comments about the bar. It’s possible to set the bar for standards at such a high level that a majority of physicians can’t implement it in a reasonable timeframe.

[ Captioner Transition ]

And the large number of different areas of standards that have been discussed in this meeting it seems to me that we are at that point of potential danger or having a concern about setting the bar so high if we really specify all of the standards that had been described that may be very difficult for many physicians and other providers to implement in a short time frame. At the same time I think it’s important to make some progress in all of those areas. It may be we are at a point where we can start to think about which are the particular areas where we want to set the bar relatively higher and some of the editor areas that have been described, perhaps part of A summary as John was describing. And having a greater level of semantic interoperability and go back to many of the same things that John Halamka mentioned with medications and labs and medications and part with the potential for adverse drug defense and a fax that you could have — effects that you could have and labs are very important but I disagree with John on the prevalence of the potential for the SnowMedCT in the near term and I would add standardized problems to that short list of things that we might want to set the bar military high air and in some of the other areas have structured messaging that we would set the bar somewhat lower for easier implementation in the short-term.

Jamie and I never disagrees.

So it’s ready for prime time. But not everybody is current, quite ready to implement.

And Wes Rishel, you have the entire group.

I appreciate your help Jamie raises an interesting point. We need to know where the will be when — where the puck will be when and the limitations that David set out very early in this meeting relative to timing leaves us to need to set the bar low so that a significant number of physicians can qualify for payment in 2011 which starts in October 2010. And yet we would hate to leave the bar there. So I think we need from the Policy Committee and the relationship of the OMC to legislature we need an understanding of how the bar will breeze over time. And that they can raise over time so that we can tree — the levels that we would set the bar at. I would ask us to consider the following facts of life if you will and our approach and in our assessment of this timing in which we can achieve measures of meaningful use and the first is a synchronous life cycle of IT systems. Whenever we put in place has to be accessible as a retrofit to systems already in use as well as accessible to a newly assigned system. And I would suggest that we not assume that what is going on at John Halamka’s Hospital is a retrofit for systems already in place. There is also the asynchronous knowledge and behavior cycle of physicians. Which is to say that they learn and they learn how to use systems and they learned the importance of what they are doing over a period of time. And if we get too far ahead of them, and our standards, then we risk a continuation of what I can only describe now as Health IT rage going on amongst physicians and when we think about the benefits to society and the health-care system of capturing and exchanging structured Data. We considered the direct impact on the position in the time spent documenting a case for creating that structured data and being made right in terms of deciding how to get the best structured data without totally disenchanting the physicians. And I think we all agree that there is a need to raise the bar. That there is a need to leave all of our standards over time — to evolve our standards over time and frozen interface syndrome when you look at the HL7 lab levels now, the industry is frozen at about 2.21 on the average which is the reason that the OSI resplacement for TCPIT guy so far as being mandated by most of the governments of the Western world and never happened. That our approach to standards initially must allow them to be upgraded asynchronous ly. And not all have to move at the same standard at the same time.

Thank you.

Thanks, Wes.

Let’s hear from Jim, last words.

I want to amplify what Wes Rishel said. Health care is incredibly complex and Health IT is complex and all kinds of things can go wrong. So it’s not just a matter of comfort and performance are productivity, it’s a matter of patient safety to make sure that we get this right. And one of Barkley expenses is is that when you implement HIT — and one of our click your experiences is that when you implement HIT so people are not overwhelmed with trying to use the new system they are not overwhelmed with basic things. We have 20 year nurses asking the shadow trainers nursing questions when using the EHR because it had not thought of their brains things they’re using for 20 years. And we did hours of testing before we went live and then we found 4192 issues in the first four weeks. And we sell 2900 of them and we had an issues list that we have to work. This is difficult to do in a way that generally improves patient care and we really need to stay serious about that particularly when we’re thinking small practices and small hospitals. We work with hospitals that have the IT people total and its crisis mode all the time for them.

Well, a thank you for that.

We have heard all realms of the spectrum. I don’t know if we had in the exuberance but we have optimism and we here caution as well. We have also heard a framing that talks about what the ultimate goals are. And yes there is a chance that bad things could have been and an even better chance that good things can happen if we move in the manner that the collective chitin’s offers. So let me take a summarize — that the guidance offers and let me summarize. We know that we have a bar out there providing information for development by 123109 and we have a fair amount of activity. And good discussion as to what are practical needs and what are contenders and we have heard dragons that the bar has to be high enough — we have heard guidance that the bar has to be high enough and they faced approach. And other comments around that in terms of where the puck will be in the challenges of life cycles associated equipment, asynchronous replacement and knowledge and behavior. And on the flip side, we have a co heard of them health professionals that are frankly very frustrated by these technologies and the former testimony and are looking not to associate without the sources of resources but what we have heard? We heard of medications and eprescribing, and understanding more about compliance. And other pieces that might be further downstream but we should not foreclosed from consideration. And labs been such a broad component. And we talked about clinical summary in a variety of ways and the need of this and this is and what concerns do they have and how do I say that this lab, medication problem do not lead to catastrophe we have heard of some pieces of that and it orients around it structured message transmission to transmit parts of that as well as the broader picture and some sort of clinical summaries that can be transmitted. And so we have a little bit of discussion on quality. And both the promise and statute proving the old and a did value of health care delivery. We started the discussion with privacy security and, indeed, that is three of the eight domains that were identified to work on. And we also heard quite — and the reminder that the patient is at the center and been able to incorporate behavior and patient outcomes including functionality and engagement in decision-making are critical elements. So we have a list of things that may meet the test and we have some aspirational aspects that may be something that escalates over time and making sure that it is accessed under the right circumstances and appropriately protected and in cages the patient. So I hope that does justice to the framing of but we will see him — about will see and an equally challenging discussion about coming to some guidance with the national coordinator. And before I give David the final word, let me turn to John Halamka for any other thoughts.

I think you did a theory good job in summarizing the discussion. I am a lumper, so far were to describe everything there is a set of administrative transactions and medical care and eprescribing and security constructs which are secure messaging, transport and, of course, things like authentication and authorization and on the disclosure. The whole security side of this and then there is the aspect of quality, not only quality measurement but outcomes, etc. so not to predispose how we would organize how to do the work but there are seemingly those broad themes encompassing all of those transactions.

To — terrific summaries. I wanted just for clarification to point out that the law does anticipate a changing use of time and that you could define standards for any aspect of contemplated meaningful use even if it’s implemented in 2020. You are not found to think just about 2011. So you can give the secretary a set of standards that are independent of time if you have time to get them done and do the things that you think we need to do in 2011. So in that sense you have a great deal of freedom to think about what your work schedule could be. There is this requirement though, that among those potentially infinite number of standards that you might develop the past to be a group that you think is appropriate for 2011.

Thank you.

We have been using this hockey analogy and sort of a famous hockey coach he said each day use the better and better and tomorrow you skate — and used it — you skate for tomorrow.

So let’s break for 15 minutes and come back at 11:00 sharp.

[ Event on break until 11:00 Eastern ]

As a reminder, please be sure to utilize the mute function, when you are not speaking.

OKE. Let’s go ahead and reconvene. The room is mercifully cooler, the average brain is 55 watts and there has been a lot of wattage in this room. So we have a couple tasks remaining and we want to hear public comment. And this last session was really critical them. Because we had taken a role of anticipating what is coming down the pike responsibly and responsive ly and these are, indeed, specified. And in the eight domains we know that three addressed the issues of privacy and security. So with your agreement, put your heads together in a little bit, and we could go standard area by Standard area but we made open to the lack of coordination. There is the intense amount of work and we will need expertise to identify potential gaps and. What if we addressed the areas of e-Prescribing, Lac Exchange and clinical summary, quality, privacy and security in three working groups. One will be critical, one will be quality, privacy, and security. And some of the other information transmission could be encompassed in that. Does that sound like a reasonable approach? Clinical, Quality, and privacy and security arm.

I did not hear an enthusiastic response from Dixie.

I was trying to hold up my card [ laughter ]

You have a comment?

The standards that we prescribed in the terminology area are used to measure quality more than likely. So it seems like they are — and Chris agrees with me, too.

That is a fair point. There seems to be a sequential and thank you being able to use the clinical data and the end goal is to be able to improve health care. So that aspect is being recognized. And maybe you could summarize the work that — You guys are correct that the atomic constructs are in clinical and there are a framework for quality measurements been devised.

There is an effort going on. I guess, a great deal of emphasis is being placed right now out on how we began to be up are set of performance measures, quality measures to use for public reporting as well as payment programs going forward as we want to leave for a payment to tie it more directly to quality information. And the role of the National Quality Forum is to endorse consensus standards, and for performance measures. We endorse the performance measures battered used by many groups both in the public — that are used by both the public and private sector. And it’s an effort that’s funded by HHS to look at the performance measures being used and to trace those down to the kind of data that needs to be captured in electronic health records and personal health records and improvement of care which is the endgame here. And going through a process initially taking a small sample of measures to identify the data types that need to be in these records. In the second one, it’s a much more expensive process to go look at the whole gamut that has been endorsed by NQF and look very closely at the workflow and not only what type of data that needs to be captured but from whom and what point does that need to be captured. So there is a good deal of going on that is very specific to quality measurement and I am not sure that would be captured in a clinical work group. Do you want to add more to that?

Here is the challenge, the folks at NQF are not getting to the HL7 X12 level, there’s a scene that you need from the standards perspective to capture and medication order, a medication administration, it was discontinued and the author of that should be a doctor, nurse, patient, and there was a set of standards that was a framework for what the data is and where the workload it was captured. It’s then handed off to the folks that are working on the more atomic data elements to say, you need medication Evan Station date time and that will be captured in this way — medication administration daytime and that will be captured in this way.

And the quality measurement piece is related closely to a critical decision support because they come from the guidelines and the evidence based. And in an ideal world when we are rolling out new quality measures or standards for public reporting we would like to be rolling out the critical decision support in the record as well to support the actual improvement process. That is the context within which this is taking place at this point. Now also I should briefly mentioned that it’s very important that that I think, that we do establish a schedule and think about when things will happen like the ICB10 because we have an analogous problem. All of these measures have been developed by many students of the measurement world and they have to be retooled with the specifications changed and retooled with SnowMed in order for this quality measurement piece to fit together with what we’re doing on the HIT side.

A number of terrific points. And here with the clinical information, as we mentioned, might aspect that I’m a little bit concerned about a band with because we have to do an awful lot. And we have to take the responsibility and ownership of it, to make sure its harmonized internally. And in terms of these areas, with some more specific areas, there’s the opportunity or the need, in fact, to identify where there are gaps. And one might imagine that there are in number of levels, from earlier discussions, what would be a reasonable starting point to make real progress at a pace with the world at looking to guidance for 2011. What sorts of things are more aspirational for 2015, 2020 etc., and how did they meet that test? What is the contribution that improves care? The statute allows for forming of subcommittees and there’s a lot of the work to do. What may be most productive is to ask the staff, to ask Judy to query each of us and see where we can contribute the most. So let’s do that in the next day. And we will have an ethics briefing, just a reminder on that, part of the process, their various rules and those names will be submitted to our federal official to identify those of committees. Does that sound like a reasonable working approach?

And the comment about how we are and to end and not just standards those committees with talk about the standards and their time frame and the implementation and there’s — their certification and David is a policy guide and certification is different than conformance testing. So to see that you exchange a transaction is one thing. And that it functionally changes the delivery of care and quality is another. So all of our committees will have to ask that broader question. E-Prescribing is fine, it’s a transaction by did you avoid medication error by doing a drug drug medication check? That is important to ask as a certification criteria.

My car is up, Wes.

Go ahead.

I think in the broad break down that you started out with, there is an area that was either overlooked or included by implication that I wanted to make clear. Which is that in addition to ensuring security and privacy and all of the things that go with security such as those that David mentioned earlier, there is the fundamental practical method of how the players get interconnected. And it’s the standards that have been done and I think we need to include perhaps a broad overview of connectivity with the security at least for the security area. Privacy almost a separate — there are a bunch of separate concepts.

Wes, the security would be secure messaging and transport among stakeholders and authentication authorization, auditing and all of those things that David has suggested.

The comments, and then we will move toward some of the public comment periods. Three comments and then we have to close by adopting a schedule, that is a statutory requirement. So we need to make sure that we do that and come to a suggestion. So we will go Jim, Kevin and then Douglis.

This is Martin Harrison, sorry I joined late can I be added to the list?

We have a bit of the time pressure to make sure that we get the public comment so you have the last word.


Is that the first or the last word?

Last word, we will come to you after Douglas.

I think Dixie’s response is natural as to how we have some label and if we have some quality would be clear about what you’re doing.

[ inaudible ]

Okay, Kevin.

To comments, one to John’s comment about moving beyond the transaction and medication management, drug interactions and that is all about are we managing the patients’ medication or are we simply exchanging transactions? I am all in favor of that and to the category of clinical. And I think it was Ann that mentioned previously the category of administrative. And while probably this group is not going to take on the task of administrative standards, your comment that you made earlier, John, we need to keep in mind those of Ministry of standards because we don’t want a large gap between what we are requiring on the administrative side and the Gap becomes wider between what we are asking positions and clinicians to do on the billing side. So I think we should add it as we recognize it’s another area not one in which this area will — to make sure it’s not completely of the performance.

And make sure includes these other areas.

As the summary comes back to each of these working groups we can put that as something that is in the purview to make sure that it’s consistent. But also recognize additionally separate areas.

Some of the focus on these three, and not the fourth, and the statute and some of the time when that are implied.

I just have a couple comments. And I appreciate all of the good work that has gone on so far. I think the first is that as the organized I hope we approach this in in — in and is a riff and incremental approach in that will be a critical path we of organizing. I think we also have in the statute the need to come out with some interim guidelines. And one would assume that eventually there would be some other guidelines to come. So we will have a process in which we start with where we are now and try to anticipate where we want to go. That process is something I think that is an important deliverable, if you will from this committee. Because every organization is going to have to say this is where we are now and this is with the standards committee told us we need to go. So we can marvel that within this committee to make sure that we have some notion about how we can get from here to there. That process I think will help articulate how we can accommodate innovation which is again a notion of change around the standards so I think although our committee is turgid with developing standards I think we need to make sure articulated an appropriate process to get out there as well. And the third thing that I wanted to see is that we talked about interoperability and Standard and thing and standards and interoperability is a continuum it’s not a binary process and this functional work process interoperability and a standard in one process does not translate itself into another even though they may look the same. So I think that is part of what we need to instruct our committee is up out is to articulate is this a semantic standard? Are there other kinds of things that are important? And as we build this out, being clear what we are trying to address. And it’s no semantics standard for interoperability.

I will make a comment because I have to leave until early. First to Douglas’ comments there many aspects of the statutes that anticipate iteration and our December 31st will so it will be subject for comment and revision. And number two there is the escalating are changing meaningful use escalation. And number three there is the emphasis on innovation. So that may take some pressure off on the wall. We have to get started and we have to move and we have to prepare for 2011 because 2011 is not the end, it is the beginning and we can build on that. I want to thank all of the committee members again and the public for being here. I regret that I will mince the public comments but if you make a comment here on our telephone connection, we make a recording of these and the office will pay close attention to them. So thank you again I book the word to seeing you sooner than probably you would care. Bye bye.

And Marty Harris is online and we want to get your comment.

Thanks, John.

I agree with the groupings and my suggestion is related to considering a fourth group as we move forward. And it speaks to this iterative nature of but we will be doing and the span of time that we will be addressing with the standards. Which are both immediate comment intermediate and long term as David said, 2020. So I think as we are doing this work we should be considering in real time how we are going to communicate effectively to all of the audiences. And I would start with all of the three working groups being able to see something that is driving their work in common and in relative real time. And then thinking about how your coin to translate that for other audiences — how you are going to translate that. And all of the other stakeholders. So it seems to me that this process clearly needs a lot of technical work to be done and I am assuming that the staff is going to meet that technical work together. And making sure that we are working toward common goals spread over a long period of time requires some dedicated effort to frame it and present it.

This is John Halamka, very good comments and we started off doing a lot of technical work and then established the educational communication and outreach committee. Exactly for your point. Taking a lot of technical standards and communicating them to a practicing physician is a great deal work. So no question we will have to figure out how to translate them and communicate in a broadly and that may be another working group and this group itself will have responsibility for knitting together the three working groups.

And I think all of us have the responsibility for working on not just the standards, certification criteria, gaps and the work to provide a rationale in an understood manner because the office of the coordinator can help to communicate and promulgate which actually taste comes to our last item of business — takes us to our last item of business. We need to adopt a calendar. It is not the standard document, but we need to adopt a process. So I would like to throw out a proposal. The first three parts are in statute and the policy committee recommends a priority for development harmonization recognition of standards and we have heard from Jodi’s description and does — and the policy to the national coordinator so that is a general working process. How rigorous to we want to be an ourselves? We know of the timeliness and we will test our collective ambition. So the real picture of this, can we create a working principle, a 93 turnaround typically, is that realistic — 90 day turnaround. And that we provide at least a report on standards, and identify what is harmonized and usable and identify gaps and the aspirations as a working product. In support of —

Just a comment, policy may ask us to do something that requires years of work but within 90 days we should say we have looked at the environment. And this piece, right off the shelf and this piece a large body of work. And we will ask the organizations to work on it to build the gap. So basically suggesting that we set a 90 day time frame from policy to output of a series of recommendations not total resolutions.

[ Speaker unclear due to low audio ]

That is why am suggesting it now for committee recommendation.

So I think we will ask Jodi to come up with some final language and typically 90 days. And understanding there are some things that are monumental. And again, per the statutue and the permissible and exceptional skills around this table and the offense they recognize the needs to receive input from voluntary organizations and others that are the developers that we adopt the process for input and recognize that as part of the calendar. So Jodi Daniels has many skills and she knows the statute backwards and forwards in sideways. Are we meeting the requirements if we adopt those two principles?

I think so. I have heard folks talking about a more specific roadmap and I think that is something that this committee can develop. If that is what is desired and I think that would be helpful for folks to give a better indication. But I think for our initial meeting and obligations it’s not — playing the role of the lawyer — I think that that would be sufficient for the time being. And with the expectation that this is something that is updated and that we can do that as Polk’s desire.

So we would agree to the process and I know the road map is — and I have heard this from multiple individuals. That they’re a lot of things coming down the pike in different channels. And whatever enthusiasm there is also the need to prepare and anticipate. And I think that is extremely helpful. So we have two cards up, Jamie.

Process question, which of the three subcommittees will address the roadmap?

[ Indiscernible ]

The combination of this 93 will the we are imposing on ourselves and that we have to produce a roadmap —

We need it in a week or two.

I think there is the desire [ laughter ]

I have never had a 90-day deadline in my life.

Are you arguing for shorter?

Will somebody sit down and back in and say that we only have a week and have to do the first pack any way?

To be very clear, I set the statute backwards, so some of our initial work needs to be done in 60 days. Is my calendar calculating rate?

Like I said, the statute does allow HHS to consider certification criteria that have gone to repair processes. So we have a starting place and have been talking about how some of the standards that have come all about process might have to some of the areas that we might want to consider for that initial sets. But to the extent particularly if there are other things, recommendations or suggestions from this group or gaps are areas that folks want to recommend that might not have gone through that prior process I think we are on a pretty tight time frame for some of that input.

There are two processes, the expedited process that gets us to the interim by no will for which we have 60 days and then there is the normal process. And the normal process would be typically 90-days.

And I think it’s very consistent with the major theme of both the statute and all of your guidance anticipating incrementalism that moves things along with building what we start with and moving further out.


I assume that all of this road map and schedule will be oriented towards the major task of meeting that deadline and that is the participation that has to occur. We have to be clear about how we are we to achieve that. But that is the priority.

Is it correct that we will in the next 48 hours or whatever try to get these work groups constitute a? Meeting next week? And the work groups when they meet, Jodi can you give to the work groups and initial mapping of the existing standards so that the work groups no what is realistic for the starter set?

I have a call Monday afternoon with all of the praetorship to ask — with all of the leadership to ask to orient them, and yes, I will take that one on.

And a related question, the 90-days the work groups have to build into their work time for them to look at and the coordination across the three work groups to take place. And the 90-days is that from today and that is when the full standards committee has approved the output of the work groups and ready to hand it over? Is that correct?

I think you’re dreaming is very good. It was alluded to earlier on some components.

So basically the work groups need to get the work done within 60 days within a meeting of this group to sort out all of that and then we can hand it out and rushed for a 90 day initial set and then think about the next iterations.

Let’s ask Judy Sparrow, we should be able to get e-mail discussion in the next 48 hours.

I will start working on it today. Absolutely.

Is this new?

Let’s go to Gina and Jim.

We want to bring that perspective only to the table.


And if, in fact, chair and vice chair want to suggest folks that are not on this committee that have an expertise that could be represented on one of those work groups that is something that we could consider within the charter to allow for augmentation of the work groups with other experts or to bring another to this type of group as appropriate. So you can let us know that.

Thanks. And again. And as the active committee there are rules in the government process and you see the statute was very clear in its intent to make sure this group.

And I want to support Ann’s contention I think the road map will be our reality orientation and we need a first draft as soon as possible so the rest of what we are considering make some kind of sense. Not final.

We hear a repeated theme and I understand the pragmatism and that interest.

Can I make a recommendation? Given the statutory deadline based on the conversation we have had here, perhaps OMC can take the responsibility to drop something up and then this is something that can be updated and revised as the committee sees fit. So if that’s okay, we can try to expedite the process.

I think that’s terrific. And one of our tasks is so that the national coordinator can work more effectively in this space. And I know when I run a project I want the roadmap and that may not be the first iteration did the first iteration may be proper conceptual terms and areas. And then we have a consensus around the general issue of our self-imposed expectation of 90-days and the process below that.

I would volunteer to give you a copy of the road map that has been effective in our work that is at a glance at the highest level to help you see with the major industry and, you know, it impacts can be and I would recommend that each work group, they will go down and sit down and create a task list. And it will be obvious for your tasks were your critical paths are so that you can create the same thing and then we can see that we are drilling to a similar checkpoint and then we will look at those things that cross to different areas and know when our coronation responsibility is.

There is a process for submitting information and we want to make sure it is available and to receive a model that he would offer. In the second yes, in each of the working groups, thinking about not only the road map but what is available in 2011 and what might be impatient for the — envisioned further along and how does it have all the attributes that are fundamental.

Let me stop to see if there are any comments from the co-chair, John?

I think you have outlined the process quite well and we will break into these committees and these will be done for Thule and we want to be green here and minimize travel. So the use of WebEx, Telephone and email and I know that you had the jobs so we try to do this as asynchronous Lee as a possibly can and try to come together and come up with initially will lead the subcommittees’ and what their task will be. And not only but that the debased guidance so that we understand the deadline on when those tasks are supposed to be complete — datebased guidance on when those tasks are supposed to be complete.

I want to thank everybody for coming and your dedication in advance. I think this will be a challenging said the issues to address and also have a great deal of impact on our ruling out of the health information technology to the larger role of health care reform.

So we will try to accommodate as many people as possible and remember the work group meetings, thankfully in the very near term, and expect to bring back the initial discussions at the next meeting.

Let’s turn now to public comment and I appreciate everyone’s patience and interest. Please state your name and organization.

They will open up the lines for the public there will be a telephone number and instructions on how to get on the line and those on the room who wish to make a comment stand at the microphone.

And I am so sorry for this morning we had a greater interest in this committee and a small room than necessary. So we apologize for anybody being turned away and we will work hard not to let this happen again.

Are the public lines open?

For those of you that our on line, the phone number and instructions are on the screen. You can dial in and press *1 to ask your question and a few are on the Fall Line press star wine to make a comment.

When do you start off the room.

Good morning and thank you for the committee work that you are about to do and this is an important project, and from MIDA from the manufacturers’ association and we are the largest trade association that represents the electrical industry. Our medical division represents over 95% of the global market. There is really no doubt that in probability assistance is crucial — interoperability assistance is crucial and you can have that unless you have speaking standards. I want to tell you more about my experience in this area. We are the leader in terms of development, deployment, and testing and also protecting the integrity of DICOM and we are involved in the HL7 standard Andes are areas in which we are very involved — and these are areas in which we are very involved. And a lot of these standards to a great degree are implemented already in a lot of different countries. I want to emphasize that you have terrifically huge time pressures here. Let us be your restores. We are involved in standards development activity for over 80 years. And we can be a great help to you. One comment I also want to make about diagnostic imaging. I don’t think there’s any argument that that is the key part of the electronic health record. And we can be of great help there as well so please don’t hesitate to call on us and we are glad to help. We shared the same goals of NHIN success an interoperability is essential to that. So I thank you and look forward to working with all of the.

Thank you for your comment.

Good morning my name is Michael and we are the world’s leading digital security company and I appreciate the opportunity to be here today. And to be able to provide some comments. I heard a bunch of things that were of great interest and a couple of things to note I heard the words patient Center, a authentication, and setting the bar. And I am sure that consumers are pretty much in favor of having an electronic help record in hopes that it will improve care and they have serious concerns about privacy and security about their information. If the bar is set to low as it pertains to authentication it will not address the public concerns. Authentication is typically done by user name and password although that is widely adopted it’s not secure and is easily compromised. And does not provide the trust as David mentioned earlier and the high assurance that the person accessing the data is who they claim to be. So hopefully as you guys work together, Stuttgart authentication techniques will be deployed to access my medical information and everyone else in the country. Thank you.

Let’s go to the phone line.

We have four people queued up.

Our first comment is from Phillip Barr with Thompson Orders.

I didn’t want to state that as you know there is a great deal of anticipation to what this committee can come out with. Both from Standards Committee to supposedly taking charge. So I would like to say that the roadmap that you talk about — and would like to offer some structures as far as tracking what is going on in the field and the bases and the direction that these are going in that area. And I would also like to ask a question, all of the folks that I know and that group and what I hear from this call are extremely confident in the right people to be there. And I would like to hear some sort of feedback, if possible to think about for the next session, maybe in 30 days which you will be offering, it is what would be — what do you feel that you need to have for the first step? I know it’s an iterative process, but the first step, the first announcement that you make that this is a priority for number one, you have a sense that you know where you want to go with that. And they’re probably different viewpoints on that but some feedback from the committee.

Let me thank you for your comments. And I don’t want to presuppose the process at a different time.


I look forward to our ongoing work and obviously these sorts of issues will be addressed.

Thank you.

Thank you.

We have another one from the phone.

Our next comment is from Joseph with Modern Healthcare Magazine.

Just to have it correct, I have clinical operations and privacy and security.

Those are the three work groups.

Very good.

That is what I want to know.


Thank you.

Ross Martin, as you pull back the lens on high-tech and health care there is the recovery Act itself and transparency and reporting on outcomes and all of that. And then there is the whole global ocarina where things are going on so — Irina going on and whether or not the purview of this committee will say whether or not we will do funding. There are a number of standards right now competing for that and a lot of the questions have been answered on that between the National Information Exchange model been promoted by DHS and in the financial community the XBRL language. Will we do a health care specific approach to that or will we incorporate that into the larger question?

This is a Health IT panel so I think the proper questions that you are asking are outside of the expected perfume of this committee — purview of this committee. And I can talk to you offline if you’re misunderstanding your concern.

Yes, I am from the American Academy of pediatrics and the interoperability work group. I want to talk above the initial standards and it identifies children as a portable population not is because of their social vulnerabilities but they get less out of health information technology and the kids across the hall in the day care center are not in the room speaking up for themselves. We have in the reauthorization Act to important targets identified in terms of immunizations and also identification of obesity and also 2.4 million newborns that been discharged from hospitals. And I did not hear about the growth data and the vaccines and the labs and some of the newborn screening and some things. Please keep this in your mind as you go forward. I did hear some response to the Chrysler Corporation in response to awareness that products out in the markets that are not used and limit the models of our standards. And there are two other important lessons from the car industry. Imagine if you move and you could not take your car with you. And imagine if you got ready to buy a new car and you could — could not pick up was car you wanted to buy. And you made some important observations about the narrative data that has to move. And in terms of the long-term roadmap you should reach a point that that is what the practice expects that they should be able to exchange patient data and opposition should have a choice in the first time.

We will all seem to be — we will all aim to do that. And looking at all of the work that is done today and mapping it into vulnerable populations, we have a team working on that.

And let the record show that the chair is married to a pediatrician.

We have one more call on the line.

Our next question from is from Fred Boar.

I am a former employee of the State of Wisconsin. Back ten years ago I worked on the HIPAA implementation and at that point I also was a member of the HIPAA metadata coalition and I recognize Chris Shuute and people for a part of your team at this point. And the in drop ability as Chris has mentioned is very important — and the interoperability is very important both that the human level and the machine level. Back in 1994 when the Web was being developed the author mentioned the semantic Web which is machine to machine. Both levels are on logic and at the human level its symbolic and at the machine level it’s a deeper level of logic. So it’s very important. So I would suggest at the outset when I worked on the metadata registry when HIPAA was implemented I loaded it from the bottom up and what I am suggesting is at the outset you involve your team in identifying the concept that you’re looking at right at the beginning of this process. Thank you.

I am happy to respond to that end we have this using that as a repository and when we talk about data elements and has been a tool for all of the work today. So certainly that recommendation is very appropriate.

I would also like to volunteer as an older American to serve in terms of any feedback in the real life use case.

Thank you very much for your comments and voluntaryism.

I want to think the entire group for participation and start by thanking the public on line, on the phone and in the room. Thank you very much and I think the statute is clear and it’s a very open process. And I want to thank the members of the committee who have traveled or made this a priority in short order and are making a very serious commitment in time over the next few months initially to meet some of the requirements that are before us. I know that everyone in this room has been driven by recognition of the shortcomings and passion for resolving those to deliver a safer and more effective more efficient accessible health care. And I would — before I adjourned the meeting formally I want to let the members of the committee know that we need to stay as part of the petrol and buys a committee — as part of the Federal Advisory Committee elements and everybody should acknowledge the great work that Judy and the staff of the office of the national coordinator has done.

[ applause ]

And with that we stand adjourned.

I’m sorry — communication will be key, so send me an e-mail about any issues or concerns.

Thank you.



4 Responses to “HIT Standards Transcript”

  1. ahier Says:

    It as a very interesting process to get these transcripts posted almost immediately after the meeting. I will continue to do this for subsequent meetings if people find it useful.

  2. Michael Magrath Says:

    I just want to let you know that I am the Michael from the world’s largest digital security company who provided the 2nd public comment at the 5/15 Standards Committee meeting.

    The reason fro my comment is that protecting an individual’s medical information and their privacy is the most important and fundamental element of an electronic health record system. If those protections are omitted then the entire system is undermined. Personal health information is highly sensitive information and warrants the need for very high confidence in the accuracy of the asserted identity of those who attempt to access it. Once it is compromised and into the wrong hands the data contained in it is irreversible and the consequences can affect the victim for his or her lifetime. An NPR poll released the week of April 20 indicated that 76% of respondents had positive impressions of EHRs, however 72% believe their privacy would be violated through EHRs. The security of personal health information is far different compared to other types of personal information including financial. Unlike financial information, there are no policies and procedures in place to restore one’s health information once it is compromised. Additionally, organizations and professionals have a fiduciary obligation to ensure transmission of information is properly authenticated between respective parties.

    Only Level 4 assurance (two or three factor authentication) as defined by National Institute of Standards and Technology (NIST) provides the highest practical assurance of remote network authentication. Level 4 authentication requires that the claimant prove through a secure authentication protocol that the claimant controls the token. Moreover, the HIEs and RHIOs will undoubtedly be targets of hackers given the nature of the information and those whose private and personal health information is contained. Level 4 authentication prevents eavesdropper, replay, online guessing, verifier impersonation, and man-in-the-middle attacks. Brookhaven National Labs states on its website that passwords are the single weakest point in the standard site-security model. The majority of security attacks are achieved through password access. User authentication that relies on passwords alone fails to provide adequate protection for network systems. Implementation of level 4 assurance by organizations in the US has resulted in a 50% reduction of such attacks.

    Similar implementations using such frameworks are widely utilized around the world by developed and developing countries for health care. For well over a decade these nations have experienced lower per capita expenditures on health care than the U.S.

    The Health Information Security and Privacy Collaboration’s (HISPC) Adoption of Standard Policies Collaborative (ASPC) report to HHS’ ONCHIT will establish the minimum requirements for authenticating users accessing electronic health records. Those minimum requirements are not two-factor or three-factor authentication via a smart card, an encrypted token or one-time password device, but rather Level 2 assurance via a “strong” password. I have concerns that stronger authentication methods are not being adopted that would assure the privacy and confidentiality of medical records by having a higher level of assurance that the person accessing the information is who they claim to be and they have a genuine need to view and access the record. It is clear that HISPC is willing to sacrifice security in order to expedite the exchange of health information.

    I have other concerns that HIEs will be architected only to meet the minimum standards of medium assurance rather than implementing strong authentication to have a very high level of assurance that the person accessing our health information is who they claim to be and have a genuine need to access the information. Any identity system requires strong authentication for the protection of personal information, especially when it is as sensitive as medical information, and consumer privacy.

    It is my hope that the HIT Policy & Standards Committees will ensure our citizens personal health information is protected by mandating at a minimum two-factor authentication into any network containing electronic health records for the protection of consumer privacy.

  3. Mark Harvey Says:

    Brian- Thanks for sharing the transcript. I’ve linked to it from my blog at healthcare-informatics.com. Please keep them coming.
    Do you know if the committee has scheduled its next meeting yet? I don’t see a date listed at healthit.hhs.gov yet…

  4. Kim norby Says:

    Brian, I do appreciate these being posted. Please continue to do so.


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